Hot Spots And Stress Fractures

As most Maryland basketball followers are well aware, the Terps have been without the services of sophomore forward Jerome Burney and freshman forward Steve Goins in recent weeks, both due to lower leg injuries. Burney suffered a stress fracture in his right foot on Dec. 9 and was expected to miss 3-6 weeks. Goins began feeling pain in his left ankle months ago and after two rounds of MRI exams it was determined he had "heat" on the outside of the ankle.

During today's ACC coaches teleconference, Gary Williams said Goins is undergoing another evaluation today but it had not yet concluded at the time of the call. Williams hoped the doctors would clear Goins to shed his protective boot and begin practicing at some point this week.

What exactly does it mean when an MRI reveals "heat" spots and how is that different from a stress fracture? I certainly had no idea, so before Saturday's game against Charlotte, I sat down for a few minutes with J.J. Bush, the Maryland basketball team's athletic trainer, to try to gain some clarity.

Bush said physical stress on bones and tendons in the human body has a similar result to repeatedly bending a coat hanger back and forth.

"After you bent it for a while and you put your finger on it, the metal would be hot, just from the stress," Bush said. "If you continued to bend it, then it would probably break. So the first part, the stress reaction, is a definition within itself. It's a reaction of your body to stress. It could be a muscle, could be a bone. In this case, we're talking about bones."

Bush said bones react to mounting physical stress by becoming thicker. There are cells called osteoblasts, which are designed to help build up the bone. There also are cells called osteoclasts, which have the opposite intention of breaking down the bone. Both types of cells are at work at the same time, and as long as there is a balance, no problem exists.

However, if the stress is greater than the bone can withstand, that's when the body starts developing what Bush called "heat action."

"It's when the stress is too great that the body can't rebuild the cells at the same rate," Bush said. "So that's like the coat hanger, if you keep bending it and bending it, it gets hot and that's a reaction to the stress you're putting onto the wire. If you continue to bend it, if you don't reduce the stress or stop the stress, and you continue to bend the wire, then it's going to break."

Typically, Bush said, stress fractures begin as stress reactions (or "heat spots," as they are revealed on MRI exams). The goal, then, is to eliminate the stresser, be it running, jumping or whatever physical activity is the source of the repeated pounding.

"You rest it for a while to allow the cells that build bone to catch up with the fact that you're breaking down cells," Bush said. "The pain is your body telling you, 'Hey, I don't like what's going on here. Pay attention to what's going on and let's stop doing this.' A lot of people have a high tolerance of pain, so they might think it's a shin splint and they might keep playing and keep going. Then, you know, when the season's over, they relax and it gets better. So they might have had a stress reaction or a stress fracture, but they're pain tolerance was high enough that they just continued to play on it. Other people with a lower pain tolerance don't cope with that as well."

Bush said stress reactions likely are far more common than they are actually reported or diagnosed. He said either the players don't report it or the trainers see it but only hold the players back a little bit because the players believe they can play through the pain.

However, Bush said, if you don't reduce the stress and the reaction continues, the chances of the bone cracking increases, which leads to a stress fracture.

"So it's a fracture caused by stress, rather than me hitting your shin with a baseball bat," Bush said.

Because of the nature of the sport -- where running up and down the court continuously is combined with frequent jumping for various reasons -- stress reactions and stress fractures are common injuries in basketball.

For that very reason, Bush takes preventative measures to try to keep the Terps from suffering the pain Burney and Goins currenty are experiencing. Each player wears custom-made orthotic arch supports in his shoes. Bush said foam rubber that makes up the padding helps absorb much of the stress the players' feet endure from all the running and jumping of daily workouts.

When dealing with stress fractures, recovery is more evident. When the fracture has healed, the player can resume workouts. But recovery time for stress reactions is more vague because the reaction's ability to limit a player's performance depends on the individual.

"If somebody says the pain is intense; it keeps me awake at night, then we have to back off," Bush said. "We have to rest 'em to allow some healing, to allow this reaction to quiet down. It's an inflammatory process, as well. By resting it, we're taking the stress off it and that allows it to calm down and feel a lot better. And then they go back out and try it again when they're pain-free. They have parameters, but depending on which bone we're dealing with, the more stress that's on it all the time, the longer it takes to heal because when you go back, you're going to put stress right back on it."

Seems to me that feet and ankles are the most overlooked part of an athlete's body and only get attention from anyone when they are causing pain. Second to them is the pelvis, how it moves or doesn't, and how that influences the hip joint and stress being put on knees, ankles and feet.

The idea of locking a foot into position my providing support where the foot has more spacing from the floor than would be ideal might sound good on paper, but I think it is exactly wrong headed.

Let be begin at the beginning. the Foot has lots of bones. Stand barefooted with your feet hip width apart and without looking down, notice the direction of each foot? Not the same is it? Now notice where the weight is on each foot, and the nature of the contact each foot makes with the ground. Notice the toes, which are hammered, which overlap on another, etc. A real mess, right?

This mess gets frozen into place by these orthodics and taping before a player takes the floor to "warm up," which invariably involves stretching, only the feet, they are not included.

The reality is that the feet can be improved dramatically, and with them, the tonus (residual tension in the muscles of the leg and hip and even more distally (far away) that cause the hammer toes, etc, if some attention is paid to working with them in a systematic fashion. Right now, trainers do not pay the least bit attention to them, except to lock them up before the fact which guarantees in my opinion that the problems with the feet will get worse, or after the fact, which is a poor substitute for other courses of action that are available.

Rich Cohen has completed his second year in a four year course of training in a collection of work about how people can learn to improve how they organize themselves for movement. The body of work, known as the Feldenkrais Method, is very highly regarded in Israel and on the Continent; there are approximately 2000 practitioners world wide. Rich is authorized by the Feldenkrais Guild to lead Awareness Through Movement classes that provide an option to, actually augment, more conventional modes of seeking to improve physical perform.